Preventable and cancer are words that are rarely used in the same sentence. When the World Health Organization (WHO) launched its global strategy to accelerate the elimination of cervical cancer by 2030, the world took notice of this particular variant of the disease.
Cervical cancer occurs in the cells of the cervix. It is caused by the human papillomavirus (HPV) strain – a sexually transmitted infection. Usually fought off by the body’s immune system, the virus occasionally manages to survive, causing it to become cancerous on those occasions. Cervical cancer is currently the fourth most common type of cancer in the world. The burden of cervical cancer is felt most intensely in low- and middle-income countries, where vaccination, screening and management take a backseat.
While over the past 26 years the burden of cervical cancer has decreased significantly (DALYs -20.2%)(1) With the implementation of the pap smear test, the question remains whether it is still the most effective test available in the Indian/Global market.
Cervical Cancer Diagnosis and WHO Guidelines
While testing of various diseases has certainly taken a back seat due to the COVID-19 pandemic, a shift in consumer awareness of the importance of diagnosis has offset the negative imbalance. HPV DNA, Pap smear, visual inspection with acetic acid (VIA), VIA with magnification, and visual inspection with Lugol’s iodine are the various diagnostic tests currently available on the market, with HPV DNA and Pap smear being the most well-known /most commonly used are .
In 2021, WHO published its second edition of guidelines for screening and treatment of precancerous lesions in cervical cancer. This recommendation was based on the rationale that a screening test must have high sensitivity (the ability of a test to correctly identify women at risk) and high negative predictive value (that women are truly diagnosed as negative, i.e. not having the disease). ). There are currently a variety of tests on the market to help screen for the HPV virus, but only one meets the WHO global standard – the HPV DNA test. WHO recommended HPV DNA testing as the primary screening test in 5 out of 7 algorithms. It is also recommended for the screen-and-treat approach.
HPV DNA VS. PAP swab test
Recommended by WHO, American Society of Clinical Oncology guidelines for secondary prevention of cervical cancer (ASCO), Federation of Obstetric and Gynecological Societies of India (FOGSI) & International Federation of Cervical Pathology and Colposcopy (IFCPC) – HPV DNA testing is considered by far to be the most effective screening option for cervical cancer.
Lower sensitivity (50% to 60%), where precancerous lesions may be missed, and a recommendation for testing every 3 years due to the possibility of detection errors are some of the main reasons for the decreasing global demand for Pap smear testing for programs in the field public health. The limitations of cytology/pap smear tests, documented in various publications, are well known since 32% of cervical cancer cases are attributed to a failed pap test.(2)
In comparison, the HPV DNA test exhibits higher sensitivity (>90%) and negative predictive value (>98%), an automated process that eliminates human error, increased reproducibility due to objective positive or negative test results, and processing steps protection from false negatives (cellularity control for human ß-globin) and false positives (no carryover contamination, no cross-reactivity) and a mandatory screening interval of 5-10 years, making it the primary screening choice of the present future. WHO has recommended that 70% of women should be screened twice in their lifetime with a high performance test – at age 35 and at age 45.
Cervical Cancer and HPV DNA Testing in India
At the moment, India is currently facing a confluence of factors contributing to its burden of cervical cancer. Research suggests that countries with a low socio-demographic index (SDI*) generally have a higher number of women who succumb to cervical cancer, as factors such as early treatment, lack of resources and stigma all contribute to the problem.
In India, ~ 160 million women between the ages of 30 and 59 are at greatest risk of developing cervical cancer(3) . Contribute to 20.51% of new cases and 22.62% of deaths worldwide(4)India’s burden of cervical cancer is growing at an alarming rate, with >123,000 new cases diagnosed annually(5) (Globokan).
As the transition to HPV DNA testing continues, India must follow suit if we are to meet the deadlines set by the WHO. With countries like Norway, UK, Netherlands, Germany, Australia, Argentina, Chile, Malaysia, Thailand, Vietnam, Belgium, France, Denmark, Malta and Turkey adopting HPV testing as the primary screening test, India needs to start with the Transition begins instead of the global deadline of 2030. A government push in close collaboration with private and public stakeholders will go a long way in reaching people on the last mile and saving lives from this preventable and curable cancer.
The views expressed above are the author’s own.
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